Evidence-based management?

The series of articles in the British Journal of General Practice have provoked some thought, for me, concerning the imminent introduction of Advanced Access to our practice. We were among the practices recruited to the National Primary Care Collaborative (NPCC) first wave. During the last 3 years we have been developing other aspects of our practice. In particular, the infrastructure, which includes both the building in which we work, and the use of the IT resources to become 'paper-light'. We have also become a personal medical services practice, in which, theoretically, patients are no longer allocated to an individual GP. Patients are, however, traditionalists, and cling to the idea of being registered with an individual practitioner. As has been noted for emergency care, 'inverting pyramids takes time'. 5 The writer of this letter to the BMJ, a consultant in accident and emergency, made the erroneous observation that 'in primary care most patients are already seen by senior doctors'. Although this is relatively correct, GPs, like hospital doctors, vary in their ability to be strictly objective with patients. In fact, the relationship between GPs and patients is one of the aspects of primary care most often cited as being important in British general practice. The emotional attachment of a patient to an individual practitioner may not be entirely 'rational', and may not correlate with clinical outcome. The idea, which appears to be gaining favour in the United States (yes, another idea from the US), coming from managed health care in health management organisations, of report cards of outcomes for individual practitioners , determined by adherence to the principles of evidence-based practice , may eventually result in greater uniformity of patient management. 6,7 Each of the articles in the BJGP raises concerns over the introduction of Advanced Access as the government's favoured method for decreasing 'wait-ing lists' in general practice. In an article from JAMA on innovations in primary care last year, two alternative models, 'the traditional' and the 'carve out' models, are described. 8 Certainly I recognise both of these, having experienced them at first hand. However, the application of industrial models in a demand-led system, for which there is little evidence of effectiveness other than qualitative evidence, concerns me. Furthermore, these models are based on Japanese, not American, ideas of re-engineering, dating from the 1980s. 9 Human beings are not commodities. One of the strongest messages that comes out of …